Follow-up care and your discharge report (informe de alta)

Terms used

• Informe de alta — The informe de alta is the written discharge report from a hospital; after emergency care you get a report of the attendance.
• Médico de cabecera — The médico de cabecera is your family doctor (GP) in the public system.
• Centro de salud — The centro de salud is your local public health centre, where your GP works.
• Urgencias — Urgencias is the emergency department of a hospital or health centre.
• Receta electrónica — The receta electrónica is the electronic prescription you collect at a pharmacy with your health card.
• Historia clínica — The historia clínica is your full clinical history held by a hospital or regional health service.

Key rules

• Bring your report: Take your own copy of the report to your GP, even if your region's system may already show it.
• Warning signs: The warning signs on your own report come before any general advice; call 112 for emergencies.
• Private providers: Private clinics are generally not linked to the public system, so ask them directly for your records.
• Records copies: Requests for a full history can take days or weeks, so ask early.

Get the report before you leave

You have the right to a written discharge report (informe de alta) after a hospital stay. After an emergency visit you get a report of the attendance. A doctor responsible for your care issues it. It can be given to you or to a person you authorise.

Check that it covers:

• your name and the centre
• the dates of admission and discharge
• the diagnosis and what was done
• the treatment to follow
• follow-up instructions and warning signs

Layouts differ by hospital and region. A line-by-line explanation of the report is below.

Take it to your family doctor

Book an appointment with your family doctor (médico de cabecera) at your centro de salud. You can usually book by app, website or phone. Bring the report. In most regions it also appears in the regional electronic record, so your GP may already see it. Do not count on that: bring your own copy.

Specialists and referrals

The hospital often books specialist appointments (citas) itself. Otherwise your GP refers you. You are usually told by letter, SMS or the regional app. If nothing arrives, ask your GP about a referral.

Medicines

Medicines prescribed at discharge are usually entered as an electronic prescription (receta electrónica). You collect them at a pharmacy with your health card. Some regions require your GP to validate the prescription first, so ask at your appointment.

When not to wait for the GP

The instructions on your own report come first. In general, go back to urgencias or call 112 for chest pain, breathing difficulty, fainting or confusion, heavy bleeding, a high fever that will not come down, severe or worsening pain, new weakness, speech or vision problems, repeated vomiting with no fluids kept down, or spreading redness, pus or swelling around a wound. If symptoms are mild, stable or slowly lingering, your GP is enough.

Seeing a doctor in another region or a private clinic

Public-system records can be shared between regions through a national platform. A doctor in another region can consult key documents such as your emergency report, discharge reports, test results and e-prescriptions. How much is available varies by region. Private providers are generally not connected, so ask them directly for your records. You can usually see your own data and who has opened it in your regional health portal or app.

Copies of your full records and moving abroad

Ask the hospital or your regional health service for a copy of your full clinical history (historia clínica) and a translated report. Requests can take days or weeks, so ask early. A template in Spanish is below. Within the EU, Spain can exchange a patient summary and e-prescription with some participating countries. Ask your regional health service which are live. Otherwise, request the copy yourself and send it.

Choosing between options

How do you get your records to the doctor who needs them?

• Rely on the regional system: You were treated in the public system, even outside your home region.

• Ask the provider directly: You were treated by a private provider. Private providers are generally not connected, so request your report and records from them and take them to your GP.

• Request a full copy and a translated report: You are moving abroad or taking your care to another country. Ask the centre for both and send them yourself. A provider sending them abroad needs your consent.

Public-system care in Spain means the regional system can share your records; private care or care abroad means you request the copy and pass it on yourself.

Documents you need

• Your discharge report (informe de alta) or, after an emergency visit, the report of the attendance. The doctor responsible issues it, and you are entitled to it. It can be handed to you or to a person you authorise.

• Your health card, needed to collect electronic prescriptions at a pharmacy.

• A copy of your full clinical history, from the hospital or from your regional health service. You only need it if you move region, use a private provider or want the whole record. Private providers must be asked directly.

• A translated copy of your report, from the centre. You only need it if you are taking your care to another country.

Checklist

• Check that your report lists your diagnosis, the treatment to follow, the follow-up instructions and the warning signs, and ask the doctor before you leave if any is missing.

• Take the report to your family doctor (médico de cabecera) at the centro de salud, booking by app, website or phone.

• Watch for a specialist appointment by letter, SMS or the regional app, and ask your GP about a referral if none arrives.

• Collect your discharge medicine at a pharmacy with your health card, and ask your GP to validate the prescription if the pharmacy cannot release it.

• Ask your regional health portal or app whether the report appears in your record, and keep your own copy.

What if you are sent home but still feel unwell?

If you still feel unwell after being sent home, the right move depends on how bad the symptoms are. Serious or getting worse: go back to urgencias or call 112. Mild or slowly lingering: see your family doctor.

Go back or call 112 straight away

Your discharge report (informe de alta) normally lists warning signs for your condition. Follow those first, because they are written for your case.

If the report does not cover it, go back to urgencias or call 112 for any of these:

• Chest pain or pressure
• Difficulty breathing
• Fainting or confusion
• Heavy bleeding
• Severe or worsening pain
• Repeated vomiting, with no fluids staying down
• A wound that shows spreading redness, pus or swelling

Do not wait for a doctor's appointment with these. 112 is free, works in several languages and is the single European emergency number. In some regions you can also call the regional health line, 061.

See your family doctor if it is stable or mild

If symptoms are mild, steady or fading slowly, book an appointment with your médico de cabecera at the centro de salud. You can usually book by app, website or phone. Take the discharge report with you.

In most regions the report appears in the regional electronic health record, so your doctor can often see it. Bring your copy anyway.

What to expect after discharge

• Specialist appointments: The hospital often arranges them, or your doctor does through a referral.
• Medication: Prescriptions from the hospital are usually added to your electronic prescription (receta electrónica). You collect them at any pharmacy with your health card. Some regions need your doctor to validate the prescription first.

If your doctor cannot see you soon and you are worried, do not sit at home. Go back to urgencias and say you were discharged recently and are not improving.

Systems and booking channels differ by region, so ask your centro de salud how it works where you live.

Request your medical records (historia clínica) in Spanish

Send this to the admissions or clinical documentation office (Admisión or Documentación Clínica) of the hospital or health centre. For a dentist, therapist or private clinic, send it to the clinic's management. Attach a copy of your passport, DNI or NIE. If someone sends it for you, they need your written authorisation and their own ID.

The centre must answer within one month, and the first copy is free. Keep proof of the date you sent it: a stamped copy if you hand it in, or the confirmation email.

Ask for the full record, not only the discharge report. Records from private providers are not linked to the public system, so each one must be asked directly. If you are moving abroad or seeing a doctor in another country, also ask for a report in English, and send the copy yourself.

Message to copy

Asunto: Solicitud de copia de mi historia clínica

A la atención del Servicio de Admisión / Documentación Clínica de [nombre del centro]:

Yo, [nombre y apellidos], con [DNI / NIE / pasaporte] número [número], y fecha de nacimiento [fecha], solicito el acceso a mi historia clínica y una copia completa de la misma.

Fui atendido/a en su centro en las siguientes fechas: [fechas o periodo], en el servicio de [servicio, por ejemplo Urgencias, Traumatología, Odontología].

Solicito en concreto:

• Informes de alta y de urgencias.
• Resultados de pruebas y análisis.
• Informes de imagen (radiografías, resonancias, etc.) y, si es posible, las imágenes.
• Tratamientos y prescripciones.
• [Otros documentos: ______]

Prefiero recibir la copia en formato [electrónico, enviada a mi correo [email] / CD / papel]. Les ruego que me indiquen si necesitan algún otro documento para tramitar la solicitud.

Les recuerdo que disponen de un mes para responder y que la primera copia es gratuita. También les ruego, si es posible, un informe clínico resumido en inglés: [sí / no].

Adjunto copia de mi documento de identidad.

Atentamente, [nombre y apellidos] [teléfono] · [email] · [fecha]

If the centre refuses or does not answer within the month, complain to your regional health authority or to the national data protection agency.

Your discharge report (informe de alta) explained line by line

Your informe de alta is the written summary of your hospital stay or emergency visit. You have the right to receive one, in public and private care. Ask the doctor before you leave, and check that you have it in your hands or in your regional health app. The layout and headings vary by hospital and region, but the sections below are the ones you will usually find.

A sample, section by section

Datos del paciente y del centro (patient and centre details) Sample: María Pérez Gil, date of birth 04/03/1980, Hospital Universitario X, health card number... Check that your name, date of birth and health card number are right. A wrong detail can cause problems when the report is filed or when you claim from insurance.

Fecha de ingreso / fecha de alta (admission and discharge dates) Sample: Admission 12/10, discharge 14/10. Keep these dates. Your employer, insurer or travel insurance may ask for them.

Servicio y médico responsable (department and doctor in charge) Sample: Traumatología, Dr. A. López. This tells you which specialist team treated you. If you have questions later, give this name and department when you call the hospital.

Motivo de ingreso o de consulta (reason for admission or visit) Sample: Pain and swelling in the right ankle after a fall. This is why you came in, in the doctor's words.

Antecedentes y exploración (history and examination) Sample: No known allergies. Takes medication for blood pressure. Ankle swollen, unable to bear weight. Check the allergies and the medication you already take. If anything is missing or wrong, tell the doctor before you leave.

Pruebas y evolución (tests and course in hospital) Sample: X-ray showed a fracture. Cast fitted. No complications. This summarises the tests done and how you responded. Keep it if another doctor needs the full picture.

Diagnóstico al alta (discharge diagnosis) Sample: Fracture of the right ankle, without displacement. This is the main line of the report. Other doctors, insurers and employers will look at it first.

Tratamiento al alta (treatment at discharge) Sample: Paracetamol every 8 hours if needed. Keep the cast dry. No weight on the foot. This is what you must do and take at home. Prescribed medication is usually loaded into the electronic prescription (receta electrónica), so you can collect it at a pharmacy with your health card. In some regions the médico de cabecera must validate it first, so ask at the pharmacy if it does not appear.

Seguimiento y recomendaciones (follow-up instructions) Sample: Review in Traumatología in 2 weeks. See your GP in 3 days. Note every appointment mentioned. Hospitals often book specialist appointments themselves and send them by letter, text message or the regional health app. If nothing arrives in the time stated, call the hospital.

Signos de alarma (warning signs) Sample: Return to emergency if you have fever, severe pain, numb or blue toes. Read this part twice. If any of these signs appear, go back to emergency without waiting for your appointment.

What to do with the report

1. Read it before you leave and ask about anything you do not understand.
2. Take it to your médico de cabecera (GP) for follow-up. In most regions the report also appears in the regional electronic clinical record, so your GP can see it, but bring a copy anyway.
3. Keep a paper or photo copy. Records do not always pass between regions, so carry it if you move or travel.
4. If you need the full clinical history rather than the report, request it from the hospital's patient services. Processes vary by region, and it can take days or weeks.

Frequently asked questions

Can my GP see my emergency report if I was treated in another region?

Yes, in the public system a doctor in one region can usually look up your emergency and discharge reports from another region, but how much appears varies by region. Bring your own copy of the report to the appointment as well.

Can I collect my discharge medicine at any pharmacy?

Yes, medicine entered in the electronic prescription (receta electrónica) can usually be collected at any pharmacy with your health card, but some regions need your GP to validate it first. If the pharmacy cannot find it, ask your GP.

Will my public GP see a report from a private hospital?

No, private providers are generally not connected to the public records system, so your GP will usually not see their report. Ask the private centre for a copy and take it to your GP.

How do I take my medical records abroad?

Ask the centre for a copy of your full record and a translated report, then send it yourself. If a provider sends it to a foreign provider, it needs your consent.